Provider Demographics
NPI:1194337170
Name:HAYNES, GRISELDA EDITH
Entity type:Individual
Prefix:
First Name:GRISELDA
Middle Name:EDITH
Last Name:HAYNES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:GRISELDA
Other - Middle Name:
Other - Last Name:VILLEGAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2118 PEMBRIDGE LN
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60431-7728
Mailing Address - Country:US
Mailing Address - Phone:815-768-7058
Mailing Address - Fax:
Practice Address - Street 1:2118 PEMBRIDGE LN
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60431-7728
Practice Address - Country:US
Practice Address - Phone:815-768-7058
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-20
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
IL222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician